Healthcare Provider Details

I. General information

NPI: 1639003080
Provider Name (Legal Business Name): KAITLIN KOO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2026
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 BRAINERD RD
ALLSTON MA
02134-4585
US

IV. Provider business mailing address

75 BRAINERD RD APT 411
ALLSTON MA
02134-4589
US

V. Phone/Fax

Practice location:
  • Phone: 857-269-8955
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: